News: 20% of patients identifying their own EHR errors, research shows

CDI Strategies - Volume 14, Issue 25

According to a study published in the Journal of the American Medical Association (JAMA), one in five patients find what they say is a mistake in their own medical records.

For this study, a survey was conducted of 136,815 patients with 29,656 providing a response. To be qualified for the survey, patients must have had at least one ambulatory note and logged onto their online medical portal at least once in the past 12 months. With this criteria, 22,889 qualified responses were available.

Of these patients, 4,830 (21.1%) reported a perceived mistake, and 2,043 of those reporting a mistake (42.3%) reported that the mistake was serious; 1,563 said the mistake was somewhat serious, while 480 noted the mistake as very serious.

In a multivariable analysis, female patients, more educated patients, sicker patients, those aged 45 and older, and those who read more than one note were more likely to report a mistake that they found to be serious compared to their reference groups.

The researchers wrote that “after categorization of patient-reported very serious mistakes, those specifically mentioning the word diagnosis or describing a specific error in current or past diagnosis were most common (98 of 356 [27.5%]).” Other very serious mistakes reported by patients include inaccurate medical history (23.9%), medications or allergies (14%), and test/procedure results (8.4%). A total of 6.5% reflected notes reportedly written on the wrong patient, and of the 433 very serious errors, 58.9% included at least one perceived error potentially associated with the diagnostic process (history, physical exam, tests, referrals, and communication).

For CDI professionals, of course, patient access to documentation provides a new impetus for documentation integrity and improvement. Not only does documentation need to support accurate coding, reimbursement, and quality reporting, stand up to potential denials, and provide accurate information to other healthcare providers, but it also needs to be understandable and accurate for patient review.

“Sharing notes with patients,” according to researchers, “may help engage them to improve record accuracy and health care safety together with practitioners.”

Editor’s note: The full JAMA study can be found here. To read about Health and Human Services’ rulings on patient access to documentation, click here.

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